Republic of the Philippines)

City
of
Davao
)S.S.
---------------------------------X

AFFIDAVIT OF OWN DAMAGE

I, _______________________, Filipino, of legal age, and a resident of

Davao City, Philippines, after having been duly sworn to in accordance with
law hereby depose and say:
1. I am the owner and driver of the vehicle described as follows:
REGISTERED OWNER
MAKE/TYPE
MOTOR/ENGINE NO.
CHASSIS NO.
PLATE NO

2. That on _____________,
I was driving the above-mentioned
vehicle along _____________________________ when suddenly a stone
flew and smashed the windshield causing damage thereto;
3. That the foregoing damage to the vehicle resulted from single
incident;
4. That I am executing this affidavit to attest as to the truth of the
foregoing in connection with the claim for own damage benefit under the
Insurance Policy which covers said vehicle.
IN WITNESS WHEREOF, I hereunto set my hand this _____, 2014 at
Davao City, Philippines.

_________________
Affiant
Drivers License bearing No. ________________
SUBSCRIBED AND SWORN to before me on this _____ day of
______________ 2014 at Davao City, Philippines, affiant having exhibited to
me the above-mentioned competent proof of Identity.
Doc No. __
Page
___
Book
VII
Series of 2014